A breath of fresh air

According to Asthma + Lung UK research published in March 2023, Blackpool, Liverpool and Inverclyde have some of the highest emergency admission and death rates for lung conditions in the country.

Many of the areas with poor lung health are areas where people experience higher levels of deprivation, which can lead to increased triggers for asthma attacks or cause lung conditions to worsen. 

The charity is urging UK governments to ensure everyone gets an early diagnosis for their lung condition and, once diagnosed, receives support and information, as well as tackle unacceptably high rates of air pollution and smoking.

In 2019, the Taskforce for Lung Health – a coalition of over 40 organisations – published an ambitious plan for reducing the UK’s lung disease burden. Four years on, considerable progress has been made, but the coalition has further recommendations to improve the diagnosis and management of lung conditions in the UK. In particular, respiratory experts are calling for additional funding so that community pharmacies can provide life-saving support to people with asthma and COPD.

“The convenience and accessibility of our sector is a valuable tool that health commissioners should be making better use of,” says Alastair Buxton, director of NHS services at Community Pharmacy England. “There is much scope to expand the services that pharmacies can offer, whether by building on existing services such as opening up access to the Smoking Cessation Service, or developing further clinical services addressing respiratory health issues. But in order to do so, as well as making sure any such proposals are properly funded and supported, NHS England and government first need to tackle the critical underlying funding and capacity challenges.”

Ongoing patient care

A report by Asthma + Lung UK in November 2022 revealed that nearly one in four respondents (COPD patients) waited five years or more for a diagnosis, and one in eight waited more than 10 years. To speed up the diagnosis of respiratory conditions, the Taskforce for Lung Health would like to see the introduction of a formal referral system to enable community pharmacists to refer customers directly to general practice or other appropriate organisations. This would also help already-diagnosed patients with new or worsening symptoms. 

“The frequency and severity of symptoms over time should be monitored to determine poor disease control,” says Kenny Chan, Numark lead information services pharmacist. “Increased need to use short-acting bronchodilator medicines and repeated courses of oral steroids could highlight a worsening of the condition, a need to re-evaluate the patient’s treatment plans or review the patient’s inhaler techniques. Meanwhile, unexplained weight loss alongside breathing issues could indicate a more sinister condition, such as cancer, and would require referral for further investigations.”

Maeve Savage and Alicia Piwko, highly specialist pharmacists (COPD and integrated respiratory care) at Guy’s and St Thomas’ NHS Foundation Trust, say that small changes can have a large impact on patient health. “Have you noticed your patients are ordering more reliever inhalers than preventer inhalers, or haven’t ordered their preventer for a long time? This is an ideal opportunity to address this with the patient,” they say. “Is their asthma well controlled? Are they aware of how important inhaled corticosteroids are in the management of their asthma? Are they aware that short-acting beta-2-agonists (SABAs) such as salbutamol don’t treat their asthma? This is the perfect time to open up a discussion and understand your patient’s perspective, finding some common ground.”

In Scotland, pharmacy support is available for self management in COPD patients to reduce hospital admissions. “We have a PGD here in Scotland to provide a rescue pack of antibiotics and steroids for COPD patients to treat an exacerbation or to keep at home,” says Helena Mills, community pharmacist in Glasgow doing independent prescribing in respiratory health. “If they present the COPD rescue medication card, they can have a maximum of two courses in three months and up to three courses in a year. If their symptoms still don’t clear up, or they’ve recently had a course of antibiotics, we refer them to their GP.”

Inhaler optimisation

An Asthma + Lung UK survey published last July suggested that one in five people with the condition are using their reliever inhaler too often. This puts them at greater risk of an asthma attack, hospitalisation and even death, because their asthma is less likely to be under control. Currently, 75,000 people are hospitalised for asthma every year, and four people die every day from an asthma attack.

Annual asthma reviews and regular inhaler checks are important in encouraging the prescribing of preventer inhalers and decreasing the use of SABA inhalers in people with asthma. These relieve symptoms, but they don’t address the underlying inflammation of the airways. This over-reliance on SABA and under-use of anti-inflammatory medicines may lead to a large portion of asthma patients living with daily uncontrolled symptoms.

Helena Mills says that in Scotland, where people don’t have to pay for prescriptions, patients understand the difference between preventers and relievers, but there is still an over-reliance on salbutamol. “Patients often pop into the pharmacy to say they’ve run out and need a new inhaler – sometimes once every three weeks,” she says. “Because they’re not paying, they don’t have to think about the cost implications. As a pharmacist, you don’t want them to go without an inhaler, but you also don’t want them using one so regularly, so you encourage them to go to their GP.”

The Taskforce for Lung Health would like an expansion of NHS Medicine Use Reviews and NHS New Medicine Services (NMS) in pharmacies, with no cap on the number pharmacies can deliver. “Community pharmacies currently offer inhaler technique checks and inhaler recycling, and ensure that spacers are being issued with pMDI’s and personalised asthma action plans,” says Darush Attar-Zadeh, a community pharmacist and executive committee member of the Primary Care Respiratory Society. “They are also involved in recognising high-risk prescribing, such as SABA over-reliance in asthma. Inhaler checks should be carried routinely and not just for the NMS. Patients need to be coached at least on an annual basis (e.g. during respiratory reviews, prescription collection) – not just on inhalers, but on all of their devices.”

The Taskforce for Lung Health is calling for community pharmacies to be funded to provide annual inhaler technique checks. “So much can be done in respiratory health through pharmacies, but the funding needs to be in place,” says Garry McDonald, a respiratory pharmacist in Scotland. “For patients with long-term conditions, prescribing through GP surgeries is often done electronically. This means that the only healthcare professional they are seeing is the pharmacist when they collect the prescription. Some patients are being switched to new inhalers by GPs via text messaging, so a healthcare professional is not demonstrating how to use them first.”

In November 2022, the Oxford Academic Health Science Network and the Guy’s and St Thomas’ Trust respiratory pharmacy team launched an evidence-based Asthma Structured Medication Review template for use with asthma patients in primary care. “Often, bad habits can creep in and it is always good to reinforce good technique, even if it means signposting the patient to inhaler technique videos on the Asthma + Lung UK website,” say Savage and Piwko. “Mixed inhaler devices are often something that gets missed in primary care – patients are perhaps prescribed a dry-powder preventer inhaler and a pressurised metered-dose reliever inhaler. These devices require different inhalation techniques, which can lead to confusion for the patient and potentially worsen asthma control. Community pharmacy could pick up on this and recommend to the GP to switch to a more appropriate inhaler device, which will streamline all devices.”

Additional pharmacy services

Stop smoking services are an essential part of primary care, especially in respiratory health. However, the Taskforce for Lung Health is concerned that with the decline in public health funding for stop smoking services, there is likely to have been a knock-on reduction in the delivery of smoking cessation training to healthcare professionals, impacting the pace and coverage of very brief advice (VBA) to all patients who smoke. 

“One advanced service that pharmacies can offer is the NHS Smoking Cessation Service,” says Jacquie Lee, Numark medication safety officer and information pharmacist. “This supports the continued provision of smoking cessation services, which were initiated for patients following discharge from hospital. Pharmacies could also be involved in locally commissioned services for smoking cessation from their ICB or local council or provide a private smoking cessation service. 

“As Healthy Living Pharmacies, a dedicated area of the premises can be used for health promotion, and this could be used to promote stop smoking services, particularly around No Smoking Day in March each year.”

Attar-Zadeh says that more should be available through community pharmacies to offer smoking cessation services specifically to tobacco users with respiratory health problems. “Currently, it’s a postcode lottery on what community pharmacies can offer,” he says. “In some areas, they can offer intensive support over six sessions and be paid. In other areas, this has been decommissioned.”

Dr Andy Whittamore, clinical lead at Asthma + Lung UK, and a practising GP, says that community pharmacists could also support people with lung conditions by advising them about non-pharmacological therapies, such as pulmonary rehabilitation, which can be beneficial for people with chronic lung disease. 

“They could also be instrumental in ensuring that vaccinations and reviews are up to date and that people are aware of the basic elements of care necessary to help them to stay well,” he says. “This includes self management plans and annual reviews with their GP surgery. A patient’s interaction with their community pharmacist is an opportunity to signpost to other local health services and useful sources of information, such as Asthma and Lung UK (www.asthmaandlung.org.uk).”